Contents

• Introduction
• Mandatory and Discretionary Rulemaking Provisions
• Congressional Oversight and the Unified Agenda
• The Unified Agenda
• This Report
• Upcoming PPACA Proposed Rules
• Timing of Upcoming Proposed Rules
• Notable Upcoming Proposed Rules
• Economically Significant or Major Proposed Rules
• "Other Significant" Upcoming Proposed Rules
• Effects on Small Entities
• Upcoming PPACA Final Rules
• Timing of Upcoming Final Rules
• Notable Upcoming Final Rules
• Economically Significant or Major Final Rules
• "Other Significant" Final Rules
• Effects on Small Entities
• PPACA Long-Term Actions
• Nature of the Long-Term Actions
• Notable Long-Term Actions
• Congressional Oversight Options

Summary

Congress delegates rulemaking authority to agencies for a variety of reasons, and in a variety of ways. The Patient Protection and Affordable Care Act (PPACA, P.L. 111-148) is a particularly noteworthy example of congressional delegation of rulemaking authority to federal agencies. A previous CRS report identified more than 40 provisions in PPACA that require or permit the issuance of rules to implement the legislation.

One way for Congress to identify upcoming PPACA rules is by reviewing the Unified Agenda of Federal Regulatory and Deregulatory Actions, which is published twice each year (spring and fall) by the Regulatory Information Service Center (RISC), a component of the U.S. General Services Administration, for the Office of Management and Budget's (OMB) Office of Information and Regulatory Affairs (OIRA). The Unified Agenda lists upcoming activities, by agency, in five separate categories or stages of the rulemaking process: the prerule stage, the proposed rule stage, the final rule stage, long-term actions, and completed actions. All entries in the Unified Agenda have uniform data elements, including the department and agency issuing the rule, the title of the rule, its Regulation Identifier Number (RIN), an abstract describing the nature of action being taken, and a timetable showing the dates of past actions and a projected date for the next regulatory action. Each entry also contains an element indicating the priority of the regulation (e.g., whether it is considered "economically significant" under Executive Order 12866, or whether it is considered a "major" rule under the Congressional Review Act).

This report examines the most recent edition of the Unified Agenda, published on December 20, 2010 (the first edition that RISC compiled and issued after the enactment of PPACA). The report identifies upcoming proposed and final rules listed in the Unified Agenda that are expected to be issued pursuant to PPACA. The Appendix lists these upcoming proposed and final rules in a table. The report also briefly discusses the long-term actions listed in the Unified Agenda, as well as some options for congressional oversight over the PPACA rules.

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Upcoming Rules Pursuant to the Patient Protection and Affordable Care Act: Fall 2010 Unified Agenda

Introduction

Federal regulations generally start with an act of Congress and are the means by which statutes are implemented and specific requirements are established. Congress delegates rulemaking authority to agencies for a variety of reasons, and in a variety of ways. The Patient Protection and Affordable Care Act (PPACA, P.L. 111-148) is a particularly noteworthy example of congressional delegation of rulemaking authority to federal agencies.¹ PPACA is a comprehensive overhaul of the health care system that includes such provisions as the expansion of eligibility for Medicaid, amendments to Medicare that are intended to reduce its growth, an individual mandate for the purchase of health insurance, and the establishment of insurance exchanges through which individuals and families can receive federal subsidies to help them purchase insurance. A previous CRS report identified more than 40 provisions in PPACA that require or permit the issuance of rules to implement the legislation.²

The rules that agencies issue pursuant to PPACA are expected to have a major impact on how the legislation is implemented. For example, in an article entitled "The War Isn't Over" that was posted on the New England Journal of Medicine's Health Care Reform Center shortly after PPACA was signed into law, Henry J. Aaron and Robert D. Reischauer wrote:

Making the legislation a success requires not only that it survive but also that it be effectively implemented. Although the bill runs to more than 2000 pages, much remains to be decided. The legislation tasks federal or state officials with writing regulations, making appointments, and giving precise meaning to many terms. Many of these actions will provoke controversy.... Far from having ended, the war to make health care reform an enduring success has just begun. Winning that war will require administrative determination and imagination and as much political resolve as was needed to pass the legislation.³

Mandatory and Discretionary Rulemaking Provisions

The manner in which Congress delegates rulemaking authority to federal agencies determines the amount of discretion the agencies have in crafting the rules and, conversely, the amount of control that Congress retains for itself. Some of the more than 40 rulemaking provisions in PPACA are quite specific, stipulating the substance of the rules, whether certain consultative or rulemaking procedures should be used, and deadlines for their issuance or implementation.⁴ Other provisions in PPACA permit, but do not require, the agencies to issue certain rules (e.g., stating that the head of an agency "may issue regulations" defining certain terms, or "may by regulation" establish guidance or requirements for carrying out the legislation). As a result, the agency head has the discretion to decide whether to issue any regulations at all, and if so, what those rules will contain. Still other provisions in PPACA require agencies to establish programs or procedures, but do not specifically mention regulations.

By December 2010, federal agencies had already issued at least 18 final rules implementing sections of PPACA.⁵ Although the legislation specifically required or permitted some of the rules to be published, other rules implemented PPACA provisions that did not specifically mention rulemaking. The use of rulemaking in these cases does not appear to be either improper or unusual; if the requirements in those rules were intended to be binding on the public, rulemaking may have been the agencies' only viable option to implement the related statutory provisions.⁶

Congressional Oversight and the Unified Agenda

In his book Building a Legislative-Centered Public Administration, David H. Rosenbloom noted that rulemaking and lawmaking are functionally equivalent (the results of both processes have the force of law), and that when agencies issue rules they, in effect, legislate. He went on to say that the "Constitution's grant of legislative power to Congress encompasses a responsibility to ensure that delegated authority is exercised according to appropriate procedures."⁷ Congressional oversight of rulemaking can deal with a variety of issues, including the substance of the rules issued pursuant to congressional delegations of authority and the process by which those rules are issued.

In order for Congress to oversee the regulations being issued to implement PPACA, it would help to have an early sense of what rules the agencies are going to issue, and when. The previously mentioned CRS report identifying the provisions in the act that require or permit rulemaking can be useful in this regard.⁸ However, the legislation did not indicate when some of the mandatory rules should be issued, some of the rules that the agencies are permitted (but not required) to issue may never be developed, and many of the rules that the agencies have already issued to implement PPACA were not specifically mentioned in the act.

The Unified Agenda

A potentially better way for Congress to identify upcoming PPACA rules is by reviewing the Unified Agenda of Federal Regulatory and Deregulatory Actions (hereafter, Unified Agenda), which is published twice each year (spring and fall) by the Regulatory Information Service Center (RISC), a component of the U.S. General Services Administration, for the Office of Management and Budget's (OMB) Office of Information and Regulatory Affairs (OIRA).⁹ The Unified Agenda helps agencies fulfill two current transparency requirements:

• The Regulatory Flexibility Act (5 U.S.C. § 602) requires that all agencies publish semiannual regulatory agendas in the Federal Register describing regulatory actions that they are developing that may have a significant economic impact on a substantial number of small entities.¹⁰
• Section 4 of Executive Order 12866 on "Regulatory Planning and Review" requires that all executive branch agencies "prepare an agenda of all regulations under development or review."¹¹ The stated purposes of this and other planning requirements in the order are, among other things, to "maximize consultation and the resolution of potential conflicts at an early stage" and to "involve the public and its State, local, and tribal officials in regulatory planning." The executive order also requires that each agency prepare, as part of the fall edition of the Unified Agenda, a "regulatory plan" of the most important significant regulatory actions that the agency reasonably expects to issue in proposed or final form during the upcoming fiscal year.

The Unified Agenda lists upcoming activities, by agency, in five separate categories or stages of the rulemaking process:

• prerule stage (e.g., advance notices of proposed rulemaking that are expected to be issued in the next 12 months);
• proposed rule stage (i.e., notices of proposed rulemaking that are expected to be issued in the next 12 months, or for which the closing date of the comment period is the next step);
• final rule stage (i.e., final rules or other final actions that are expected to be issued in the next 12 months);
• long-term actions (i.e., items under development that agencies do not expect to take action on in the next 12 months); and
• completed actions (i.e., final rules or rules that have been withdrawn since the last edition of the Unified Agenda).

All entries in the Unified Agenda have uniform data elements, including the department and agency issuing the rule, the title of the rule, its Regulation Identifier Number (RIN),¹² an abstract describing the nature of action being taken, and a timetable showing the dates of past actions and a projected date (sometimes just the projected month and year) for the next regulatory action. Each entry also contains an element indicating the priority of the regulation (e.g., whether it is considered "economically significant" under Executive Order 12866, or whether it is considered a "major" rule under the Congressional Review Act).¹³

There is no penalty for issuing a rule without a prior notice in the Unified Agenda, and some prospective rules listed in the Unified Agenda never get issued, reflecting the fluid nature of the rulemaking process. Nevertheless, the Unified Agenda can help Congress and the public know what regulatory actions are about to occur, and it arguably provides federal agencies with the most systematic, government-wide method to alert the public about their upcoming proposed rules. A previously issued CRS report indicated that about three-fourths of the significant proposed rules published after having been reviewed by OIRA in 2008 were previously listed in the "proposed rule" section of the Unified Agenda.¹⁴

This Report

The December 20, 2010, edition of the Unified Agenda and Regulatory Plan is the first edition that RISC has compiled and issued after the enactment of PPACA.¹⁵ Federal agencies were required to submit data to RISC for the Unified Agenda by September 10, 2010, although some of the agencies did not submit the data until early October.¹⁶ Therefore, the information in the Unified Agenda is current as of September/October 2010.

This report examines the December 20, 2010, edition of the Unified Agenda and identifies upcoming proposed and final rules and long-term actions that are expected to be issued pursuant to PPACA. To identify those upcoming rules and actions, CRS searched all fields of the Unified Agenda (all agencies) using the term "affordable care act," focusing on the proposed rule and final rule stages of rulemaking, and also including the "long-term actions" category. CRS excluded from the results any regulatory action that mentioned PPACA or health care reform, but did not appear to be an action taken to implement the legislation.¹⁷

The results of the search for proposed and final rules are provided in the Appendix to this report. For each upcoming proposed and final rule listed, the table identifies the department and agency expected to issue the rule, the title of the rule and its RIN, an abstract describing the nature of the rulemaking action, and the date that the proposed or final rule was expected to be issued.¹⁸ The abstracts presented in the table were taken verbatim from the Unified Agenda entries, although CRS sometimes used other information from the entries to identify the section of PPACA being implemented by the regulatory action when the agency-provided abstracts did not do so. Within the proposed and final rule sections of the table, the entries are organized by the expected dates of issuance, with the earliest dates presented first. Regulatory actions that the agencies considered important enough to be part of the regulatory plan are identified with a double asterisk (**) after the RIN.

Upcoming PPACA Proposed Rules

The December 20, 2010, edition of the Unified Agenda listed 29 PPACA-related actions in the "proposed rule stage" (indicating that the agencies expected to issue proposed rules on the topics within the next 12 months, or for which the closing dates of the comment periods are the next step). All but 2 of the 29 upcoming proposed rules were expected to be issued by components of the Department of Health and Human Services (HHS): the Centers for Medicare and Medicaid Policy (CMS, 15 actions); the Office of Consumer Information and Insurance Oversight (OCIIO, 4 actions); the Office of the Secretary (4 actions); the Food and Drug Administration (FDA, 2 actions); the Administration on Aging (AOA, 1 action); and the Health Resources and Services Administration (HRSA, 1 action). One other proposed rule was expected to be issued by the Department of Labor's Employee Benefits Security Administration (EBSA), and one was expected to be issued by the Department of the Treasury's Departmental Offices (DO).

Timing of Upcoming Proposed Rules

The agencies indicated that four of the upcoming proposed rules would be issued in December 2010. One of these, an HHS/CMS proposed rule on "Use of Recovery Audit Contractors," was actually published in November 2010.¹⁹ As of December 31, 2010, the other three upcoming proposed rules had not been published: a CMS rule on "Payment Adjustment for Health Care-Acquired Conditions"; a Treasury/Departmental Offices rule on "Review and Approval Process for Waivers for State Innovation"; and an OCIIO rule on "Affordable Care Act Waiver for State Innovation; Review and Approval Process."

The agencies indicated that eight other proposed rules would be published in the first three months of 2011:

• two CMS rules on "Medicare Shared Savings Program: Accountable Care Organizations," and "Federal Funding for Medicaid Eligibility Determination and Enrollment Activities," which were expected to be published in January 2011;
• two CMS rules on "Community First Choice," and "Requirements for Long-Term Care Facilities: Notification of Facility Closure," which were expected to be published in February 2011;
• two OCIIO rules on "Requirements To Implement American Health Benefit Exchanges and Other Provisions of the Affordable Care Act" and "Transparency Reporting," which were expected to be published in March 2011; and
• two FDA rules on "Food Labeling: Nutrition Labeling for Food Sold in Vending Machines" and "Food Labeling: Nutrition Labeling of Standard Menu Items in Chain Restaurants," which were expected to be published on March 23, 2011.

The HHS Office of the Secretary said it expected to issue three proposed rules in April 2011,²⁰ and CMS said it expected to issue eight proposed rules between April and July 2011.²¹

Notable Upcoming Proposed Rules

HHS agencies considered 6 of the 29 upcoming proposed rules important enough to be included in the regulatory plan:

• a CMS rule on "Medicare Shared Savings Program: Accountable Care Organizations," which the agency indicated would be issued sometime during the month of January 2011;
• a CMS rule on "Requirements for Long-Term Care Facilities: Notification of Facility Closure," which the agency said it expected to issue sometime during the month of February 2011;
• an OCIIO rule on "Transparency Reporting," which the agency said would be issued sometime during the month of March 2011;
• an FDA rule on "Food Labeling: Nutrition Labeling for Food Sold in Vending Machines," which is required to be issued by March 23, 2011 the one-year anniversary of the enactment of PPACA;
• an FDA rule on "Food Labeling: Nutrition Labeling of Standard Menu Items in Chain Restaurants," which is also required to be issued by March 23, 2011; and
• an AOA rule on "Community Living Assistance Services and Supports Enrollment and Eligibility Rules Under the Affordable Care Act," which the agency expected to issue sometime during the month of September 2011.

Economically Significant or Major Proposed Rules

In addition to the upcoming PPACA-related proposed rules that were listed in the regulatory plan, the Unified Agenda lists six other upcoming PPACA-related proposed rules that the agencies considered "economically significant" or "major" (one definition of "economically significant" or "major," for example, is that the rule is expected to have at least a $100 million annual effect on the economy):

• a CMS rule on "Federal Funding for Medicaid Eligibility Determination and Enrollment Activities," which was published on November 8, 2010, with comments due by January 7, 2011;²²
• a CMS rule on "Use of Recovery Audit Contractors," which was expected to be issued sometime during December 2010 (but was actually issued on November 10, 2010);²³
• an OCIIO rule on "Affordable Care Act Waiver for State Innovation; Review and Approval Process," which was expected to have been issued sometime during December 2010;
• an OCIIO rule on "Requirements To Implement American Health Benefit Exchanges and Other Provisions of the Affordable Care Act," which was expected to be issued sometime during March 2011;
• a CMS rule on "Home and Community-Based Services (HCBS) State Plan Services Program," which was expected to be issued sometime during July 2011; and
• an OCIIO rule on "Public Use Files of Health Plan Data," which was expected to be issued sometime during September 2011.

"Other Significant" Upcoming Proposed Rules

In addition to the above-mentioned rules, the agencies characterized several other upcoming proposed rules implementing PPACA as "other significant" in the Unified Agenda, indicating that although they were not listed in the regulatory plan or expected to be "economically significant," they were expected to be significant enough to be reviewed by OIRA under Executive Order 12866.²⁴ These proposed rules included

• an HHS Office of the Secretary rule on "Exceptions to the Beneficiary Inducement Prohibition for Certain Arrangements," which was expected to be issued sometime during March 2011;
• a DOL/EBSA rule "Ex Parte Cease and Desist and Summary Seizure Orders Under ERISA Section 521," which was expected to be issued sometime during July 2011; and
• a CMS rule on "Long-Term Care Facility Quality Assessment and Performance Improvement," which was expected to be issued sometime during January 2012.

Effects on Small Entities

The Regulatory Flexibility Act (5 U.S.C. §§ 601-612) generally requires federal agencies to assess the impact of their forthcoming regulations on "small entities" (i.e., small businesses, small governments, and small not-for-profit organizations).²⁵ Three of the previously mentioned upcoming PPACA-related proposed rules were expected to affect small businesses, small governments, or both, and were expected to require a regulatory flexibility analysis:

• the FDA rules on "Food Labeling: Nutrition Labeling for Food Sold in Vending Machines," and "Food Labeling: Nutrition Labeling of Standard Menu Items in Chain Restaurants"; and
• the CMS rule on "Federal Funding for Medicaid Eligibility Determination and Enrollment Activities."

In addition to these rules, five other upcoming proposed rules were expected to have an effect on small businesses, small governments, or small not-for-profits, but were not expected to trigger the requirements of the Regulatory Flexibility Act. These included

• a CMS proposed rule on "Long-term Facility Quality Assessment and Performance Improvement";
• an HHS/Office of the Secretary proposed rule on "Exceptions to the Beneficiary Inducement Prohibition for Certain Arrangements"; and
• a Treasury/DO proposed rule on "Review and Approval Process for Waivers for State Innovation."

Upcoming PPACA Final Rules

The December 20, 2010, edition of the Unified Agenda listed 18 PPACA-related actions in the "final rule stage" (indicating that the agency expected to issue final rules on the subjects within the next 12 months). Eight of the upcoming final rules were expected to be issued by CMS; four by OCIIO; two by DOL/EBSA; and one each by HRSA, the Internal Revenue Service within the Department of the Treasury, the Occupational Safety and Health Administration (OSHA) within DOL, and the Social Security Administration.

Timing of Upcoming Final Rules

The agencies indicated that 6 of the 18 upcoming final rules would be issued during the month of December 2010. Two of these rules were published before the Unified Agenda was issued on December 20, 2010:

• a CMS rule on "Changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System for CY 2011," which was published in late November 2010;²⁶ and
• a Social Security Administration rule on "Regulations Regarding Income-Related Monthly Adjustment Amounts to Medicare Beneficiaries' Prescription Drug Premiums," which was published in early December 2010.²⁷
• As of December 31, 2010, the other four final rules that the agencies indicated would be published during December 2010 had not been published:
• an IRS rule on "Indoor Tanning Services";²⁸
• an OCIIO rule on "Rate Review";²⁹
• an OCIIO rule on "Health Care Reform Insurance Web Portal Requirements"; and
• a CMS rule on "Adult Health Quality Services."

The agencies indicated that nine other final rules would be published in the first seven months of 2011:

• two CMS rules scheduled for January 2011 on "Additional Screening, Application Fees, and Temporary Moratoria for Providers and Suppliers,"³⁰ and "Children's Health Insurance Program (CHIP); Allotment Methodology and States' Fiscal Year 2009 CHIP Allotments";
• an OCIIO rule scheduled for March 2011 on "Uniform Explanation of Benefits, Coverage Facts, and Standardized Definitions";
• a CMS rule scheduled for March 2011 on "Civil Money Penalties for Nursing Homes";
• two DOL/EBSA rules scheduled for April 2011 on "Group Health Plans and Health Insurance Issuers Relating to Dependent Coverage of Children to Age 26 Under the Patient Protection and Affordable Care Act," and "Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act";³¹
• two CMS rules scheduled for June 2011 on "Administrative Simplification: Adoption of Authoring Organizations for Operating Rules and Adoption of Operating Rules for Eligibility and Claims Status," and "Proposed Changes to the Demonstration Review and Approval Process";³² and
• a CMS rule scheduled for July 2011 on "Administrative Simplification: Standard Unique Identifier for Health Plans."

Notable Upcoming Final Rules

The agencies considered 3 of the 18 upcoming PPACA-related final rules important enough to be included in the regulatory plan:

• an OCIIO rule that was scheduled for December 2010 on "Rate Review";
• a CMS rule scheduled for March 2011 on "Civil Money Penalties for Nursing Homes"; and
• an OCIIO rule scheduled for March 2011 on "Uniform Explanation of Benefits, Coverage Facts, and Standardized Definitions."

Economically Significant or Major Final Rules

In addition to the upcoming PPACA-related final rules that were listed in the regulatory plan, the Unified Agenda lists five other upcoming PPACA-related final rules that the agencies considered "economically significant" or "major" (e.g., that are expected to have at least a $100 million annual effect on the economy):

• three CMS rules on "Changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System for CY 2011," "Children's Health Insurance Program (CHIP); Allotment Methodology and States' Fiscal Year 2009 CHIP Allotments," and "Additional Screening, Application Fees, and Temporary Moratoria for Providers and Suppliers";
• an OCIIO rule on "Medical Loss Ratios"; and
• a DOL/EBSA rule on "Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act."

"Other Significant" Final Rules

In addition to the above-mentioned rules, five other upcoming final rules implementing PPACA were characterized as "other significant" in the Unified Agenda, indicating that although they were not listed in the regulatory plan or expected to be "economically significant," they were expected to be significant enough to be reviewed by OIRA under Executive Order 12866. These final rules were

• a HRSA rule on "Designation of Medically Underserved Populations and Health Professional Shortage Areas";
• two CMS rules on "Adult Health Quality Services" and "Proposed Changes to the Demonstration Review and Approval Process";
• a DOL/OSHA rule on "Procedures for the Handling of Retaliation Complaints Under Section 1558 of the Affordable Care Act of 2010"; and
• a Social Security Administration rule on "Regulations Regarding Income-Related Monthly Adjustment Amounts to Medicare Beneficiaries' Prescription Drug Premiums."

Effects on Small Entities

Two of the upcoming final rules were expected to trigger the requirements of the Regulatory Flexibility Act because of their effects on small businesses: the IRS rule on "Indoor Tanning Services," and the CMS rule on "Changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System for CY 2011." Four other CMS rules were expected to have an effect on small businesses, governments, or other organizations, but were not expected to require a regulatory flexibility analysis: (1) "Children's Health Insurance Program (CHIP); Allotment Methodology and States' Fiscal Year 2009 CHIP Allotments"; (2) "Administrative Simplification: Adoption of Authoring Organizations for Operating Rules and Adoption of Operating Rules for Eligibility and Claims Status"; (3) "Administrative Simplification: Standard Unique Identifier for Health Plans"; and (4) "Additional Screening, Application Fees, and Temporary Moratoria for Providers and Suppliers."

PPACA Long-Term Actions

As noted earlier in this report, the Unified Agenda also identifies "long-term actions" (i.e., regulatory actions that are under development in the agencies that the agencies do not expect to take action on in the next 12 months). The December 20, 2010, edition of the Unified Agenda listed 24 long-term actions related to PPACA. In comparison to the proposed and final rules previously discussed, it is much less clear when the PPACA-related long-term actions are expected to occur; in 15 of the 24 cases, the agencies said that the dates for the actions were "to be determined." Of the remaining nine long-term actions, six were expected in December 2011, and one each in calendar years 2012, 2013, and 2014.

Nature of the Long-Term Actions

Of the 24 long-term actions, 11 were upcoming final rules that were expected to be issued once the agency had considered the comments received in response to previously issued interim final rules.³³ These actions included

• a DOL/EBSA rule on "Group Health Plans and Health Insurance Issuers Relating to Internal and External Appeals Processes Under the Patient Protection and Affordable Care Act;" with the date of the final rule "to be determined";³⁴ and
• an HHS/OSCIIO rule on "Internal Claims, Appeals, and External Review Processes Under the Affordable Care Act," with the date of the final rule "to be determined."³⁵

Five other long-term actions were upcoming IRS final rules that the agency expected to issue by the end of calendar year 2011 after considering the comments received in response to a previously issued notice of proposed rulemaking. These actions included

• "Requirements Applicable to Grandfathered Health Plans Under the Patient Protection and Affordable Care Act";³⁶ and
• "Requirements Applicable to Group Health Plans and Health Insurance Issuers Under the Patient Protection and Affordable Care Act."³⁷

Other examples of PPACA-related long-term actions included

• an HHS/Indian Health Service advance notice of proposed rulemaking (ANPRM) on "Standards for the Planning, Design, Construction and Operation of Health Care and Sanitation Facilities," with the publication date "to be determined";³⁸
• two IRS upcoming final rules on "Prohibition of Preexisting Condition Exclusions or Other Discrimination Based on Health Status Under the Patient Protection and Affordable Care Act," and "Coverage of Preventive Services Under the Patient Protection and Affordable Care Act;" both of which were expected to be published sometime during December 2011; and
• a DOL/Office of Workers' Compensation Program upcoming proposed rule entitled "Regulations Implementing Amendments to the Black Lung Benefits Act: Determining Coal Miners and Survivors Entitlement to Benefits," with an expected publication sometime during the month of March 2012.

Notable Long-Term Actions

The agencies identified 7 of the 24 PPACA-related long-term actions as both "economically significant" and "major" rulemaking actions. All seven of these actions were cases in which the agencies had issued interim final rules and were reviewing the comments received. These included

• HHS/OSCIIO actions covering such topics as a "Pre-Existing Condition Insurance Plan," "Preventive Services Under the Affordable Care Act" and "Dependent Coverage of Children to Age 26 Under the Patient Protection and Affordable Care Act"; and
• a DOL/EBSA action entitled "Group Health Plans and Health Insurance Coverage Relating to Status as a Grandfathered Health Plan Under the Patient Protection and Affordable Care Act."

The agencies considered 11 of the 24 actions to be "other significant," meaning that the agencies considered them significant enough to be reviewed by OIRA under Executive Order 12866, but not "economically significant." These actions included

• two CMS actions entitled "Administrative Simplification: Adoption of Standard and Operating Rule for Electronic Funds Transfer (EFT) and Operating Rule for Remittance Advice" and "State Option to Provide Health Homes for Enrollees with Chronic Conditions"; and
• an HHS/HIS action on "Confidentiality of Medical Quality Assurance Records; Qualified Immunity for Participants."

Congressional Oversight Options

As noted earlier in this report, when federal agencies issue substantive regulations, they are carrying out legislative authority delegated to them by Congress. Therefore, it is appropriate for Congress to oversee the rules that agencies issue to ensure that they are consistent with congressional intent and the rulemaking requirements established in various statutes and executive orders. In order for Congress to oversee the rules being issued pursuant to PPACA, it must first know that they are being issued—ideally as early as possible. The Unified Agenda is perhaps the best vehicle to provide that early information, describing not only what rules are expected to be issued, but also providing information regarding their significance and timing.

Congress has a range of tools available to oversee the rules that federal agencies are expected to issue to implement PPACA, including oversight hearings and confirmation hearings for the heads of regulatory agencies. Individual members of Congress may also participate in the rulemaking process by, among other things, meeting with agency officials and filing public comments.³⁹ Congress, committees, and individual members can also request that the Government Accountability Office (GAO) evaluate the agencies' rulemaking activities.

Another option is the Congressional Review Act (CRA, 5 U.S.C. §§801-808), which was enacted in 1996 to establish procedures detailing congressional authority over rulemaking "without at the same time requiring Congress to become a super regulatory agency."⁴⁰ The act generally requires federal agencies to submit all of their covered final rules to both houses of Congress and GAO before they can take effect.⁴¹ It also established expedited legislative procedures (primarily in the Senate) by which Congress may disapprove agencies' final rules by enacting a joint resolution of disapproval.⁴² The definition of a covered rule in the CRA is quite broad, arguably including any type of document (e.g., legislative rules, policy statements, guidance, manuals, and memoranda) that the agency wishes to make binding on the affected public.⁴³ After these rules are submitted, Congress can use the expedited procedures specified in the CRA to disapprove any of the rules. CRA resolutions of disapproval must be presented to the President for signature or veto.

For a variety of reasons, however, the CRA has been used to disapprove only one rule in the 14 years since it was enacted.⁴⁴ Perhaps most notably, it is likely that a President would veto a resolution of disapproval to protect rules developed under his own administration, and it may be difficult for Congress to muster the two-thirds vote in both houses needed to overturn the veto. Congress can also use regular (i.e., non-CRA) legislative procedures to disapprove agencies' rules, but such legislation may prove even more difficult to enact than a CRA resolution of disapproval (primarily because of the lack of expedited procedures in the Senate), and if enacted may also be vetoed by the President.

Although the CRA has been used only once to overturn an agency rule, Congress has regularly included provisions in the text of agencies' appropriations bills directing or preventing the development of particular regulations. Such provisions include prohibitions on the finalization of particular proposed rules, restrictions on certain types of regulatory activity, and restrictions on implementation or enforcement of certain provisions.⁴⁵ Appropriations provisions can also be used to prompt agencies to issue certain regulations, or to require that certain procedures be followed before or after their issuance. The inclusion of regulatory provisions in appropriations legislation as a matter of legislative strategy appears to arise from two factors: (1) Congress's ability via its "power of the purse" to control agency action, and (2) the fact that appropriations bills are considered "must pass" legislation. Congress's use of regulatory appropriations restrictions has fluctuated somewhat over time, and previous experience suggests that they may be somewhat less frequent when Congress and the President are of the same party.⁴⁶

Appendix. Upcoming Proposed and Final Rules Pursuant to the Patient Protection and Affordable Care Act

Footnotes

1.	For more information on PPACA, see CRS Report R40942, Private Health Insurance Provisions in the Patient Protection and Affordable Care Act (PPACA), by [author name scrubbed], [author name scrubbed], and [author name scrubbed]; CRS Report R41278, Public Health, Workforce, Quality, and Related Provisions in PPACA: Summary and Timeline, coordinated by [author name scrubbed] and [author name scrubbed]; CRS Report R41196, Medicare Provisions in the Patient Protection and Affordable Care Act (PPACA): Summary and Timeline, coordinated by [author name scrubbed]; and CRS Report R41210, Medicaid and the State Children's Health Insurance Program (CHIP) Provisions in PPACA: Summary and Timeline, coordinated by [author name scrubbed].
2.	CRS Report R41180, Regulations Pursuant to the Patient Protection and Affordable Care Act (PPACA), by [author name scrubbed].
3.	Henry J. Aaron and Robert D. Reischauer, "The War Isn't Over," New England Journal of Medicine, Health Care Reform Center, March 24, 2010, available at http://healthcarereform.nejm.org/?p=3223&query=home.
4.	Although the law contains a number of deadlines for the issuance of rules, rulemaking deadlines are generally somewhat difficult to enforce, unless the statute itself contains an enforcement mechanism. None of the provisions in PPACA contain a legislative enforcement mechanism, so the remaining options for enforcement include political pressure on the agencies or civil litigation, although courts often defer to agencies' judgment on the timing of their issuance of a rule.
5.	CRS Report R41346, Initial Final Rules Implementing the Patient Protection and Affordable Care Act, by [author name scrubbed].
6.	Case law and guidance from OMB indicate that agencies should not attempt to bind affected parties through policy statements and other non-rule documents. See, for example, Appalachian Power Co. v. Environmental Protection Agency, 208 F.3d 1015 (D.C. Cir. 2000); and Office of Management and Budget, "Final Bulletin for Agency Good Guidance Practices," 72 Federal Register 3432, January 25, 2007, which states (on p. 3433) that "The courts, Congress, and other authorities have emphasized that rules which do not merely interpret existing law or announce tentative policy positions but which establish new policy positions that the agency treats as binding must comply with the (Administrative Procedure Act's) notice-and-comment requirements, regardless of how they initially are labeled."
7.	David H. Rosenbloom, Building a Legislative-Centered Public Administration: Congress and the Administrative State, 1946-1999 (Tuscaloosa, AL: The University of Alabama Press, 2000), pp. 133-134.
8.	CRS Report R41180, Regulations Pursuant to the Patient Protection and Affordable Care Act (PPACA), by [author name scrubbed].
9.	The current edition of the Unified Agenda is available at http://www.reginfo.gov/public/do/eAgendaMain.
10.	This requirement applies to all agencies covered by the Administrative Procedure Act (5 U.S.C. 551(1)).
11.	Executive Order 12866, "Regulatory Planning and Review," 58 Federal Register 51735, Oct. 4, 1993. Although most of the requirements in this executive order do not apply to independent regulatory agencies (e.g., the Securities and Exchange Commission), this section includes these agencies.
12.	RINs are assigned by RISC, and the Office of Management and Budget has asked agencies to include RINs in the headings of their rulemaking documents when they are published in the Federal Register to make it easer for the public and agency officials to track the publication history of regulatory actions. For a copy of this memorandum, see http://www.whitehouse.gov/sites/default/files/omb/assets/inforeg/IncreasingOpenness_04072010.pdf.
13.	Section 3(f) of Executive Order 12866 defines a "significant" regulatory action as one that is likely to result in a rule that may "(1) Have an annual effect on the economy of $100 million or more or adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, or tribal governments or communities; (2) Create a serious inconsistency or otherwise interfere with an action taken or planned by another agency; (3) Materially alter the budgetary impact of entitlements, grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) Raise novel legal or policy issues arising out of legal mandates, the President's priorities, or the principles set forth in this Executive order." Regulatory actions meeting the first of these four criteria are considered "economically significant." The definition of a "major" rule under the Congressional Review Act (5 U.S.C. §§801-808) is essentially the same as "economically significant."
14.	CRS Report R40713, The Unified Agenda: Implications for Rulemaking Transparency and Participation, by [author name scrubbed].
15.	PPACA was enacted on March 23, 2010. Although the spring edition of the Unified Agenda was published after that date, the data were submitted to RISC before PPACA was enacted.
16.	E-mail from John Thomas, Director, Regulatory Information Service Center, January 4, 2010.
17.	For example, one proposed rule entry stated that the regulatory action would help state governments "prepare for the implementation of health care reform," but the legal authority for the action was not PPACA. Therefore, that entry was not included in the table in the Appendix.
18.	In addition to the RINs, CMS included an agency-specific number as part of the title of the rule (e.g., CMS-1345-P). Those numbers are included as part of the title in the table in the Appendix.
19.	U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, "Medicaid Program; Recovery Audit Contractors," 75 Federal Register 69037, November 10, 2010. PPACA required that the final rule be issued by December 31, 2010, but as of that date the final rule had not been published.
20.	These upcoming proposed rules are "Exceptions to the Beneficiary Inducement Prohibition for Certain Arrangements," "Revisions to the Office of Inspector General's (OIG) Exclusion Authorities," and "Safe Harbors to the Anti-Kickback Statute for Certain Arrangements."
21.	These upcoming proposed rules are "Covered Outpatient Drugs," "Request for Information on Availability of Medicare Data for Performance Measurement," "Home Health Physician Encounter," "Omnibus Physician and Supplier Enrollment," "Medicaid Automated Data System Requirements and Data Elements Necessary for Program Integrity, Program Oversight, and Administration," "5-Year Period Approvals and Renewals for Waivers and Demonstration Projects," "Medicaid Reconsideration of Disallowance," and "Home and Community-Based Services (HCBS) State Plan Services Program."
22.	U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, "Medicaid; Federal Funding for Medicaid Eligibility Determination and Enrollment Activities," 75 Federal Register 68583, November 8, 2010.
23.	U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, "Medicaid Program; Recovery Audit Contractors," 75 Federal Register 69037, November 10, 2010.
24.	Executive Order 12866 requires covered agencies (all except independent regulatory agencies like the Securities and Exchange Commission) to submit their "significant" rules to OIRA for review before publication as a proposed or final rule. For more information, see CRS Report RL32397, Federal Rulemaking: The Role of the Office of Information and Regulatory Affairs, by [author name scrubbed].
25.	For more information, see CRS Report RL34355, The Regulatory Flexibility Act: Implementation Issues and Proposed Reforms, by [author name scrubbed].
26.	U.S. Department of Health and Human Services, Centers for Medicare and Medicaid, "Medicare Program: Hospital Outpatient Prospective Payment System and CY 2011 Payment Rates; Ambulatory Surgical Center Payment System and CY 2011 Payment Rates; Payments to Hospitals for Graduate Medical Education Costs; Physician Self-Referral Rules and Related Changes to Provider Agreement Regulations; Payment for Certified Registered Nurse Anesthetist Services Furnished in Rural Hospitals and Critical Access Hospitals; Final Rule," 75 Federal Register 71800, November 24, 2010.
27.	U.S. Social Security Administration, "Regulations Regarding Income-Related Monthly Adjustment Amounts to Medicare Beneficiaries' Prescription Drug Coverage Premiums," 75 Federal Register 75884, December 7, 2010.
28.	A related proposed rule and a "final and temporary regulation" were published on June 15, 2010.
29.	OCIIO did, however, publish a proposed rule regarding this issue on December 23, 2010.
30.	CMS published a proposed rule on this issue on September 23, 2010.
31.	Both of these final rules would finalize interim final rules that had been issued in 2010.
32.	CMS published a proposed rule on this issue on September 17, 2010.
33.	Interim final rules are a particular application of the "good cause" exception to notice-and-comment rulemaking (5 U.S.C. § 553), in which the agency issues a final rule without a prior notice of proposed rulemaking, but with a post-promulgation opportunity for the public to comment. Interim final rules often take effect immediately, but the effective dates may also be delayed.
34.	The associated interim final rule was published on June 17, 2010 (75 Federal Register 34538), but subsequently amended on November 17, 2010 (75 Federal Register 70114).
35.	The associated interim final rule was published on July 23, 2010 (75 Federal Register 43330).
36.	The associated notice of proposed rulemaking was published on June 17, 2010 (75 Federal Register 34571).
37.	The associated notice of proposed rulemaking was published on May 13, 2010 (75 Federal Register 27141).
38.	According to the Unified Agenda, an ANPRM is "a preliminary notice, published in the Federal Register, announcing that an agency is considering a regulatory action. An agency may issue an ANPRM before it develops a detailed proposed rule. An ANPRM describes the general area that may be subject to regulation and usually asks for public comment on the issues and options being discussed. An ANPRM is issued only when an agency believes it needs to gather more information before proceeding to a notice of proposed rulemaking."
39.	For example, in Sierra Club v. Costle (657 F.2d 298, D.C. Cir. 1981), the D.C. Circuit concluded (at 409) that it was "entirely proper for congressional representatives vigorously to represent the interests of their constituents before administrative agencies engaged in informal, general policy rulemaking, so long as the individual Members of Congress do not frustrate the intent of Congress as a whole as expressed in statute, nor undermine applicable rules of procedure."
40.	Joint statement of House and Senate Sponsors, 142 Cong. Rec. E571, at E571 (daily ed. April 19, 1996); 142 Cong. Rec. S3683, at S3683 (daily ed. April 18, 1996).
41.	If a rule is considered "major" (e.g., has a $100 million annual effect on the economy), then the CRA generally prohibits it from taking effect until 60 days after the date that it is submitted to Congress.
42.	For a detailed discussion of CRA procedures, see CRS Report RL31160, Disapproval of Regulations by Congress: Procedure Under the Congressional Review Act, by [author name scrubbed].
43.	For more on the potential scope of the definition of a "rule" under the CRA, see CRS Report RL30116, Congressional Review of Agency Rulemaking: An Update and Assessment of The Congressional Review Act after a Decade, by [author name scrubbed].
44.	The rule overturned in March 2001 was the Occupational Safety and Health Administration's ergonomics standard. This reversal was the result of a unique set of circumstances in which the incoming President (George W. Bush) did not veto the resolution disapproving the outgoing President's (William J. Clinton's) rule. See CRS Report RL30116, Congressional Review of Agency Rulemaking: An Update and Assessment of The Congressional Review Act after a Decade, by [author name scrubbed], for a description of several possible factors affecting the CRA's use, and for other effects that the act may have on agency rulemaking.
45.	See CRS Report RL34354, Congressional Influence on Rulemaking and Regulation Through Appropriations Restrictions, by [author name scrubbed].
46.	Ibid., p. 35. This report indicated that some appropriations restrictions were repeated every year for 10 years, some were repeated several years in a row but then stopped, and some appeared in only one appropriations bill. Some restrictions appeared to be intended to stop particular rules issued at the end of presidential administrations.